A key constraint to achieving the MDGs is the absence of a properly trained and motivated workforce. Loss of clinical staff from low and middle-income countries is crippling already fragile health care systems. Health worker retention is critical for health system performance and a key problem is how best to motivate and retain health workers. The authors undertook a systematic review to consolidate existing evidence on the impact of financial and non-financial incentives on motivation and retention.

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Motivation and retention of health workers in developing countries: a systematic review.

Context: Large-scale, whole-systems interventions in health care require imaginative approaches to evaluation that go beyond assessing progress against predefined goals and milestones. This project evaluated a major change effort in inner London, funded by a charitable donation of approximately $21 million, which spanned four large health care organizations, covered three services (stroke, kidney, and sexual health), and sought to “modernize” these services with a view to making health care more efficient, effective, and patient centered.

Methods: This organizational case study draws on the principles of realist evaluation, a largely qualitative approach that is centrally concerned with testing and refining program theories by exploring the complex and dynamic interaction among context, mechanism, and outcome. This approach used multiple data sources and methods in a pragmatic and reflexive manner to build a picture of the case and follow its fortunes over the three-year study period. The methods included ethnographic observation, semistructured interviews, and scrutiny of documents and other contemporaneous materials. As well as providing ongoing formative feedback to the change teams in specific areas of activity, we undertook a more abstract, interpretive analysis, which explored the context-mechanism-outcome relationship using the guiding question “what works, for whom, under what circumstances?”

Findings: In this example of large-scale service transformation, numerous projects and subprojects emerged, fed into one another, and evolved over time. Six broad mechanisms appeared to be driving the efforts of change agents: integrating services across providers, finding and using evidence, involving service users in the modernization effort, supporting self-care, developing the workforce, and extending the range of services. Within each of these mechanisms, different teams chose widely differing approaches and met with differing success. The realist analysis of the fortunes of different subprojects identified aspects of context and mechanism that accounted for observed outcomes (both intended and unintended).

Conclusions: This study was one of the first applications of realist evaluation to a large-scale change effort in health care. Even when an ambitious change program shifts from its original goals and meets unforeseen challenges (indeed, precisely because the program morphs and adapts over time), realist evaluation can draw useful lessons about how particular preconditions make particular outcomes more likely, even though it cannot produce predictive guidance or a simple recipe for success. Noting recent calls by others for the greater use of realist evaluation in health care, this article considers some of the challenges and limitations of this method in the light of this experience and suggests that its use will require some fundamental changes in the worldview of some health services researchers.

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How Do You Modernize a Health Service? A Realist Evaluation of Whole-Scale Transformation in London

The first paper in this series on building the field of Health Policy and Systems Research (HPSR) in low- and middle-income countries (LMICs) [1] outlined the scope and questions of the field and highlighted the key challenges and opportunities it is currently facing. This paper examines more closely one key challenge, the risk of disciplinary capture—the imposition of a particular knowledge frame on the field, privileging some questions and methodologies above others. In HPSR the risk of disciplinary capture can be seen in the current methodological critique of the field, with consequences for its status and development (especially when expressed by research leaders).

The main criticisms are reported to be: that the context specificity of the research makes generalisation from its findings difficult; lack of sufficiently clear conclusions for policy makers; and questionable quality and rigour [2]. Some critique is certainly warranted and has come from HPS researchers themselves. However, this critique also reflects a clash of knowledge paradigms, between some of those with clinical, biomedical, and epidemiological backgrounds and those with social science backgrounds. Yet, as HPSR is defined by the topics and questions it considers rather than a particular disciplinary approach, it requires engagement across disciplines; indeed, understanding the complexity of health policy and systems demands multi- and inter-disciplinary inquiry [3].

To develop the science of HPSR it is, therefore, important to start by recognising the diversity of disciplinary perspectives, as well as shared concerns. Richer methodologies for addressing these concerns must then be developed. And, as health policies and systems are themselves social and political constructions, it is important to acknowledge the particular value of social science perspectives in the field. Each of these issues is addressed in the following sections, and they are considered further in paper three of the series [4].

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Building the field of health policy and systems research: social science matters.

Each year in Uganda 141 000 children die before reaching their fifth birthday; 26% of these children die in their first month of life. In a setting of persistently high fertility rates, a crisis in human resources for health and a recent history of civil unrest, Uganda has prioritized Millennium Development Goals 4 and 5 for child and maternal survival. As part of a multi-country analysis we examined change for newborn survival over the past decade through mortality and health system coverage indicators as well as national and donor funding for health, and policy and programme change. Between 2000 and 2010 Uganda's neonatal mortality rate reduced by 2.2% per year, which is greater than the regional average rate of decline but slower than national reductions in maternal mortality and under-five mortality after the neonatal period. While existing population-based data are insufficient to measure national changes in coverage and quality of services, national attention for maternal and child health has been clear and authorized from the highest levels. Attention and policy change for newborn health is comparatively recent. This recognized gap has led to a specific focus on newborn health through a national Newborn Steering Committee, which has been given a mandate from the Ministry of Health to advise on newborn survival issues since 2006. This multi-disciplinary and inter-agency network of stakeholders has been able to preside over a number of important policy changes at the level of facility care, education and training, community-based service delivery through Village Health Teams and changes to essential drugs and commodities. The committee's comprehensive reach has enabled rapid policy change and increased attention to newborn survival in a relatively short space of time. Translating this favourable policy environment into district-level implementation and high quality services is now the priority.

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Newborn survival in Uganda: a decade of change and future implications

Existing definitions and measurement approaches of quality of health care often fail to address the complexities involved in understanding quality of care. It is perceptions of quality, rather than clinical indicators of quality, that drive service utilization and are essential to increasing demand. Here we reflect on the nature of quality, how perceptions of quality influence health systems and what such perceptions indicate about measurement of quality within health systems. We discuss six specific challenges related to the conceptualization and measurement of the quality of care: perceived quality as a driver of service utilization; quality as a concept shaped over time through experience; responsiveness as a key attribute of quality; the role of management and other so-called upstream factors; quality as a social construct co-produced by families, individuals, networks and providers; and the implications of our observations for measurement. Within the communities and societies where care is provided, quality of care cannot be understood outside social norms, relationships, trust and values. We need to improve not only technical quality but also acceptability, responsiveness and levels of patient-provider trust. Measurement approaches need to be reconsidered. An improved understanding of all the attributes of quality in health systems and their interrelationships could support the expansion of access to essential health interventions.

Understanding and measuring quality of care: dealing with complexity.

Despite the expanding literature on how reforms may affect health workers and which reactions they may provoke, little research has been conducted on the mechanisms of effect through which health sector reforms either promote or discourage health worker performance. This paper seeks to trace these mechanisms and examines the contextual framework of reform objectives in Uganda and Bangladesh, and health workers' responses to the changes in their working environments by taking a 'realistic evaluation' approach. The study findings were generated by triangulating both qualitative and quantitative methods of data collection and analysis among policy technocrats, health managers and groups of health providers. Quantitative surveys were conducted with over 700 individual health workers in both Bangladesh and Uganda and supplemented with qualitative data obtained from focus group discussions and key interviews with professional cadres, health managers and key institutions involved in the design, implementation and evaluation of the reforms of interest. The reforms in both countries affected the workforce through various mechanisms. In Bangladesh, the effects of the unification efforts resulted in a power struggle and general mistrust between the two former workforce tracts, family planning and health. However positive effects of the reforms were felt regarding the changes in payment schemes. Ugandan findings show how the workforce responded to a strong and rapidly implemented system of decentralisation where the power of new local authorities was influenced by resource constraints and nepotism in recruitment. On the other hand, closer ties to local authorities provided the opportunity to gain insight into the operational constraints originating from higher levels that health staff were dealing with. Findings from the study suggest that a) reform planners should use the proposed dynamic responses model to help design reform objectives that encourage positive responses among health workers b) the role of context has been underestimated and it is necessary to address broader systemic problems before initiating reform processes, c) reform programs need to incorporate active implementation research systems to learn the contextual dynamics and responses as well as have inbuilt program capacity for corrective measures d) health workers are key stakeholders in any reform process and should participate at all stages and e) some effects of reforms on the health workforce operate indirectly through levels of satisfaction voiced by communities utilising the services.

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Ahmed Mustafa

Papers

Health sector reforms and human resources for health in Uganda and Bangladesh: mechanisms of effect